Provider Demographics
NPI:1376641027
Name:WILLIAM E MOSS PSC
Entity Type:Organization
Organization Name:WILLIAM E MOSS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:502-366-0392
Mailing Address - Street 1:4801 MANSLICK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-4097
Mailing Address - Country:US
Mailing Address - Phone:502-366-0392
Mailing Address - Fax:502-366-7086
Practice Address - Street 1:4801 MANSLICK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-4097
Practice Address - Country:US
Practice Address - Phone:502-366-0392
Practice Address - Fax:502-366-7086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY16800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY90004094Medicaid
KY1209301Medicare PIN
KYC71598Medicare UPIN
KY90004094Medicaid